VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Virginia Beach
937 Diamond Springs Road
Virginia beach, VA 23455
(757) 493-9535

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: May 11, 2020 and May 13, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on May 11, 2020 and concluded on May 13, 2020. A complaint was received by the department regarding allegations in the areas of admission, retention and discharge of residents, buildings and grounds, and additional requirements for facilities that care for adults with serious cognitive impairments. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The licensing representative reviewed resident records, reviewed staff schedules, and documentation regarding door repair, and conducted interviews. Licensing staff could not substantiate building cleanliness based on interviews. The following was discussed: Individualized Service Plan (ISP) signatures and Fall Risk Ratings. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice. The complaint is not valid. Please review, sign, date, and return the Violation Notice, Supplemental, and Summary pages to include your facility's plan of corrections. Please submit your ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice in a Word document and return it within 10 calendar days. The plan of correction must indicate how the violation will be or has been corrected. The plan of correction must include: 1. Step(s) to correct the noncompliance with the standard(s) 2. Measures to prevent reoccurrence 3. Person(s) responsible for implementing each step and/or monitoring any preventative measures. Additionally, please contact me if you would like to review your Violation Notice via phone.

Violations:

Standard #:	22VAC40-73-1110-A
Complaint related:	No
Description:	Based on record review and discussion, the facility failed to ensure prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee determined whether placement in the special care unit was appropriate, and the determination and justification for the decision as in writing and retained in the resident?s file. Evidence: 1. Resident #1 admitted 11-26-19, and resident #2 admitted 03-31-20. The residents? files did not contain determination and justification for placement into the safe secure environment by the licensee, administrator, or designee. 2. During discussion, Staff #1 acknowledged the determination and justification for placement by the licensee, administrator, or designee to a safe, secure environment was not completed. Staff #1 stated that resident #1 admitted prior to her time working at the facility.
Plan of Correction:	1. On the day of the inspection an immediate correction was made. The Executive Director/Health and Wellness Director completed or update documentation for placement into a safe secure environment for resident #1 and resident # 2. 2. The Executive Director or Designee will provide education for Health and Wellness Director and Resident Care Coordinator on Virginia required documentation for placement into a safe secure environment and Virginia regulations to be completed by 5/29/2020. 3. The Health and Wellness Director, Resident Care Coordinator or Designee will audit current resident records for documentation for placement into a safe secure environment to be completed by 6/30/2020. 4. The Health and Wellness Director, Resident Care Coordinator Designee will randomly audit current resident records for compliance with documentation for placement into a safe secure environment and regulations once a month for three months.